Provider First Line Business Practice Location Address:
201 17TH AVE E APT 308
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98112-5280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-957-8190
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2026